Official vows to end ‘deplorable’ practice of ‘boarding’ mentally ill

King County’s top mental-health administrator has pledged to eliminate the controversial practice of warehousing severely mentally ill patients in hospital emergency rooms while they await proper treatment.

It’s an admittedly ambitious goal, given that nine of every 10 patients who were involuntarily admitted for psychiatric care in King County this February experienced the practice — officially called “psychiatric boarding” — according to data Jim Vollendroff presented to a Metropolitan King County Council committee hearing this week.

That’s a sharp increase from the same month in 2013, when six of every 10 were boarded.

“It’s not something that we can just sit back and wait for somebody else to address,” said Vollendroff, recently appointed director of the county’s mental-health division. “I really do operate from this position of being constantly dissatisfied with the status quo, because the status quo means individuals are not getting the care that they need.”

Last year, a Seattle Times investigation exposed the epidemic of hospitals boarding mentally ill patients across Washington, finding the practice quintupled from 2009 to 2012 in King County. Patients wait an average of three days without treatment, at times strapped to their beds and forcibly medicated without further psychiatric care. Unprepared nurses face safety risks from unpredictable patients, the examination found.

The problem stems from a shortage of beds set aside specifically for detained psychiatric patients. In 2013, Harborview Medical Center alone boarded almost 1,000 patients who were detained on 72-hour orders by a mental-health professional and couldn’t immediately be placed in the hospital’s 61-bed psychiatric unit or any of the three other county facilities used for involuntary treatment, according to data provided by Harborview. The hospital boarded an additional 120 who were committed to long-term orders — usually 90 days — but couldn’t be promptly transferred to Western State Hospital for treatment.

“We’re at the point where it wouldn’t matter whose loved one got detained,” said Darcy Jaffe, chief nurse officer at Harborview. “We wouldn’t have a bed for them. It could be the president’s wife. Seriously, there would not be a bed for the person.”

A “deplorable” practice

At Tuesday’s meeting, Vollendroff laid out measures to curb the problem, including helping the Washington State Hospital Association in its effort to address the bed shortage, working on a new 16-bed facility expected to open next year in King County and freeing up more next-day psychiatric appointments that could prevent mentally ill people from reaching a point where they require commitment. He noted the plan was a work in progress, and said he would present more recommendations in the near future.

Calling boarding “a deplorable way to treat people,” he assured the committee he’s determined to bring the high rate in King County down to zero.

“I do believe it’s possible to end this practice,” he said in an interview.

Vollendroff also discussed the confluence of factors exacerbating the problem. While Seattle’s population is growing rapidly, the state Legislature has continued to cut funding for mental-health services over the past five years. There’s also been an increase in the number of patients being involuntarily detained in recent years, due in part to a decline in resources and jobs during the recession, experts say.

The committee asked Vollendroff to return in coming months with updated information and a concrete timeline to reduce boarding.

“We need a lot of adjustments to try to make this as humane a process as we possibly can,” Councilmember Kathy Lambert said in an interview.

Things could get worse

Despite Vollendroff’s optimism, the problem could get worse before it gets better, said Chelene Whiteaker, policy director for the Washington State Hospital Association. In July, new criteria for involuntary treatment will go into effect that tells mental-health professionals to begin considering information from certain credible witnesses during the evaluation process, such as family members and neighbors, and likely will increase the number of people who qualify to be detained.

“I think, in the short term, things are going to get worse when the involuntary treatment changes are in place,” said Whiteaker. “Patients are obviously needing care. They’re very sick. We will see increased boarding in the short term.”

Whiteaker lamented how the bed shortage trickles down the levels of the mental health system, clogging every step of the way. When patients are committed to long-term psychiatric care facilities but can’t be placed immediately in beds, they temporarily take up beds in short-term care facilities.

With an increase in momentum and awareness to the issue, however, Whiteaker expressed hope for progress in the next year or two.

Others around the state also are taking measures to curb the boarding issue. Washington legislators addressed boarding this session in a mental-health investment that included, among other funding, $7 million to beef up the number of psychiatric-care beds. Some experts, however, question how much these measures will actually do to help.

The Joint Commission, a Chicago-based federal regulatory agency, recently forced EvergreenHealth Medical Center in Kirkland to step up its emergency-room treatment of mentally ill patients after an investigation found several deficiencies, including failing to appropriately care for patients waiting to be transferred and giving medication but not counseling to boarded patients.

Others are taking creative measures with the resources available. Harborview has created a makeshift psychiatric unit in its emergency department, which includes treatment from psychiatrists and mental-health nurses.

“We’ve set up, to the degree it’s possible, a care team that can provide fairly closely the same level of care they’d get once they get up to the psychiatric department,” said Jaffe. “Of course, the emergency room isn’t the same as the psychiatric unit.”

Jaffe and others are also working with the county and state on long-term improvements, such as finding housing for mentally ill people and advocating to legislators on the issue.

“It’s not an easy solution,” said Jaffe, “because if it was, we would have done it already.”